Incorporating Public Values Through Multiple Accountability: A Case Study on Quality Regulation of Emergency Care in the Netherlands by an Independent Regulatory Agency

Published date01 July 2022
Date01 July 2022
Subject MatterArticles
Administration & Society
2022, Vol. 54(6) 1178 –1206
© The Author(s) 2021
Article reuse guidelines:
DOI: 10.1177/00953997211057056
Incorporating Public
Values Through Multiple
Accountability: A
Case Study on Quality
Regulation of Emergency
Care in the Netherlands
by an Independent
Regulatory Agency
Jolien van de Sande1, Bert de Graaff1,
Diana Delnoij1,2, and Antoinette de Bont1
In this paper, we explore how multiple accountability (MA) can enable an
independent regulatory agency to deal with multiple conflicting public values
in a complex and politically salient decision-making process. We examined
the decision-making process of the Dutch National Health Care Institute
on quality regulation of emergency care in the Netherlands. Using insights
derived from ethnography, document analysis, and interviews, we show that
MA resulted from strategic interactions between the Institute’s vertical and
horizontal accountability forums. We argue that MA impeded efficiency but
also enabled the Institute to deal with multiple conflicting public values.
public accountability, multiple accountability, public values, conflicting values,
independent regulatory agencies, emergency care
1Erasmus University Rotterdam, The Netherlands
2National Health Care Institute, Diemen, The Netherlands
Corresponding Author:
Jolien van de Sande, Erasmus School of Health Policy and Management, Erasmus University
Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands.
1057056AAS0010.1177/00953997211057056Administration & Societyvan de Sande et al.
van de Sande et al. 1179
Since the 1980s, the privatization and reregulation of public services in the
context of new public management reforms has led to a shift from govern-
ment to systems of dispersed governance in many European countries
(Bovens & Schillemans, 2014; Majone, 1994). These developments have
restricted hierarchical influence and have sparked a tendency to introduce
new accountability practices to overcome accountability deficits in policy-
making (Schillemans, 2011). A large body of accountability research focuses
on the public accountability of independent regulatory agencies (IRAs), to
which governments have increasingly delegated tasks (Helderman et al.,
2012; Majone, 1994). As ministerial control on these agencies is limited, they
are not affected by traditional democratic accountability through elections
(Durose et al., 2015).
This accountability deficit is particularly perceived as pressing since agen-
cies often execute substantive tasks. Therefore, they give a certain meaning
to political values when making decisions and these analyses cannot be laid
down in legal procedures (Bach & Jann, 2010; Eriksen, 2021; Majone, 1996).
Although much research has been done on value conflict, finding better ways
to deal with different values remains a pressing issue for policymakers
(Kernaghan, 2003). Besides coping with different (often conflicting) values,
agencies must deal with numerous accountability practices because of their
accountability deficit. This phenomenon is called multiple accountability
(MA). Scholars have largely focused on the drawbacks of MA, such as high
costs, pressure on public officials, politicization, and confusion (Flinders,
2011; Koppell, 2005; Willems & Van Dooren, 2012).
However, the benefits of MA, such as increased reliability of oversight
and reduction of information asymmetry, have also been investigated
(Schillemans, 2010). In our ethnographic study, we will focus on the benefit
addressed by both Scott (2000) and Schillemans (2010), who state that MA
balances different values because different forums have competing agendas,
concerns, powers, procedures, and capacities. Previous empirical research
that addresses how organizations and individuals deal with competing values
and accountability shows the often complex, messy, and political nature of
these processes. Oldenhof et al. (2014) conducted observations and inter-
views to show how public managers use justifications to deal with value con-
flicts in their daily work. Brunsson (1989, pp. 4–9) finds that, to survive,
organizations strategically try to gain legitimacy through the creation of
structures, processes, and ideologies which reflect the inconsistent norms in
their environment. The well-known garbage can process that Cohen et al.
(1972) describe is more coincidental. It stresses that outcomes are determined

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